First Name: *
Last Name: *
Middle Name:
Have you ever been a member of USA Swimming under a different last name?

Previously registered with USA Swimming: *
If yes:
Preferred Name:
Date of Birth: *
Sex: *
Club Code:
Club Name: *
Mailing Address: *
City: *
State: *
Zip: *
Home Phone Number:
Work Phone Number:
Mobile Phone Number:
Email Address: *
Race and Ethnicity(optional): (up to two choices)






Citizenship/FINA: *
U.S. Citizen:
Member of another FINA?:

Check if you would like to learn more about USA Swimming Foundation's initiatives
Check if you would like to receive USA Swimming's electronic newsletter
Membership Code: * (check all that apply)
Coach-Full Time
Coach-Part Time
Certified Official
Other
 
(Empoyed full time as a coach)
(Primary employment is NOT coaching)
(Starter, Stroke & Turn, Meet Referee, Administrative, etc.)
(Chaperone, Meet Directory, Meet Manger, etc.)
If coach, primary age group that you coach: (May be more than one)
10-Un 11-12 13-14 15-18 19+ Masters
ALL NON-ATHLETES must have a current USA Swimming Background Check and Athlete Protection Training
BGC at www.usaswimming.org/backgroundcheck
APT at www.usaswimming.org/protect
COACHES: Also requires current CPR/AED & Safety Training for Swim Coaches certification
EDUCATION REQUIREMENT FOR COACHES: at www.usawsimming.org/FOC
  • An individual registering as a coach for ht first time must complete the online Foundations of Coaching 101 test prior to becoming a Coach Member
  • Prior to registering as a coach for the second year, the online tests for Foundation of Coaching 201 and Rules and Regulations must be completed
ACCEPTABLE SAFETY REQUIREMENT COURSES AND ONLINE TESTS ARE AVAILABLE AT: www.usaswimming.org/coachmember
2019 REGISTRATION FEE
September 1, 2018 thru December 31, 2019
 
USA Swimming Fee
+
LSC Fee
=
Total Due
Individual
$60.00
+
$10.00
=
$70.00
Life
$1,000.00
+
$10.00
=
$1010.00
CREDIT CARD BILLING INFORMATION


First Name: *
Last Name: *
Email: *
Address Line 1: *
Address Line 2:
City: *
State: *
Postal Code: *
Card Number: *
Card Verification Number: *
Expiration Date: *

By submitting this application I verify that the above is true and correct